From the Guidelines
Hemorrhagic cysts less than or equal to 5 cm in premenopausal women require no further management, while those greater than 5 cm but less than 10 cm should be followed up in 8-12 weeks. This approach is based on the most recent and highest quality study, which provides a consensus guideline for the management of hemorrhagic cysts 1. The study suggests that typical hemorrhagic cysts in the premenopausal age group that are less than or equal to 5 cm can be managed conservatively without the need for further intervention. However, when the cyst is greater than 5 cm but less than 10 cm, follow-up in 8-12 weeks is recommended to monitor for any changes in size or characteristics.
Key Considerations
- Hemorrhagic cysts should not occur in the postmenopausal population, and therefore, any cysts found in this age group should be further evaluated by a specialist or with an MRI study 1.
- The risk of malignancy in benign-appearing lesions on ultrasound, including hemorrhagic cysts, is less than 1% 1.
- Unilocular cysts, including hemorrhagic cysts, have a very low risk of malignancy, with a recent meta-analysis showing a risk of 0.6% in premenopausal women 1.
- Conservative management with nonsteroidal anti-inflammatory drugs (NSAIDs) and rest is often sufficient for managing symptoms, while surgery is reserved for cases with severe symptoms, large cysts, or complications like torsion or rupture.
Management Approach
- For premenopausal women with hemorrhagic cysts less than or equal to 5 cm, no further management is necessary.
- For premenopausal women with hemorrhagic cysts greater than 5 cm but less than 10 cm, follow-up ultrasound in 8-12 weeks is recommended.
- For postmenopausal women with hemorrhagic cysts, further evaluation by a specialist or with an MRI study is recommended due to the low likelihood of hemorrhagic cysts in this age group.
- Patients should be advised to seek medical attention if they experience severe pain, fever, vomiting, dizziness, rapid breathing, or shoulder pain, as these may indicate complications requiring surgical intervention.
From the Research
Hemorrhagic Cyst Management Options
- Surgical management has been a traditional approach in managing corpus luteum haemorrhage, however, conservative management is now dominating the trend in carefully selected patients 2.
- Emergency laparoscopy is an established technique for diagnosis and management of hemorrhagic ovarian cysts, but its availability is limited in underserved areas due to high maintenance costs and lack of trained personnel 3.
- Transvaginal ultrasound-guided aspiration is a less radical treatment option for simple ovarian cysts, with a cumulative rate of cyst recurrence of 20.2% among 84 patients 4.
- Laparoscopic surgery is a viable option for the treatment of peritoneal inclusion cysts, with reduced mean length of hospital stay, estimated blood loss, and complication rate compared to laparotomic surgery 5.
Conservative Management
- Conservative management can be successful in selected patients with haemorrhage secondary to deranged coagulation, and may involve the use of cyclical oral Desogestrel for long-term ovulation suppression 2.
- Conservative management may not always be possible, and timely surgical intervention may be necessary to reduce morbidity and mortality, especially in cases of recurrent hemorrhagic ovarian cysts due to coagulopathy 6.
Surgical Intervention
- Surgical intervention may be necessary in cases where conservative management is not possible or has failed, and may involve laparoscopic cystectomy, adnexectomy, or a second aspiration 4.
- Laparoscopic surgery has been shown to be superior to laparotomic surgery for the treatment of peritoneal inclusion cysts, with reduced estimated blood loss, complication rate, and hospital stay 5.